Occupational Skin Occupational Skin DiseasesDiseases

Introduction Introduction

The second cause of occupational diseases ( 23-25% of all occ.diseases )

A skin disease that is caused by physical, biological or chemical factor in work

Also a worsening of pre-existing skin disease can be termed as occupational skin disease (Psoriasis , Acne)

Absenteesm & CostAbsenteesm & Cost

4 million working days are lost due to occupational skin disease and the UK Health & Safety Executive has calculated an associated cost to British industry of £200 million per year.

Work place agentsWork place agentsthat induced skin disorderthat induced skin disorder

ChemicalsAcidsAlkalisSolventsOilsDetergentsResinsPlasticsMetalsPetroleum productPlant & wood

PhysicalsTemperature Ionizing radiationNon ionizing radiation

BiologicViruses (orf-wart-herpes)Bacteria(anthrax-erisopeloid)Fungi(candida-dermatophyte)Parasites(scabies-(schistosomiasis)

MechanicalsPressureFrictionVibration

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Important causal agents of Important causal agents of occupational skin illnessoccupational skin illness

Machinery ◦ Cutting oils

◦ Solvents

Metal products ◦ Solvents

◦ Metallic salts

Electronic equipment ◦ Solvents

◦ Plastic & resin

Food products ◦ Fruits & vegetables◦ Soap & detergents

Agriculture ◦ Chemicals

◦ Fruits & nuts

Health services ◦ Soap & detergents◦ Infectious agents

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Diagnosis Of Occupational Skin Diagnosis Of Occupational Skin DiseasesDiseasesHistory : present illness,

occ.information, personal historyP/EDiagnostic techniquesSupplemental information

QuestionsQuestionsWhen did disease start?In which skin area was the first

symptom?What is work technique?Free time, other worksCleaning measuresProtectionVacation, holidays

Classification of skin diseaseClassification of skin disease

Occupational dermatitisOccupational photosensitivity reactionsOccupational phototoxicity reactionOccupational skin cancersOccupational contact urticariaOccupational acneOccupational skin infectionsOccupational pigmentary disordersMiscellaneous

Case 1Case 1

Erythema , dryness and itching on the right hand of a printer man

What is your diagnosis ?

Contact DermatitisContact Dermatitis Occupational dermatitis is an inflammation of the skin

causing itching, pain, redness, swelling and small blisters.

Contact dermatitis is an eczematous eruption caused by external agents, which can be broadly divided into:

◦ Irritant substances that have a direct toxic effect on the skin (irritant contact dermatitis, ICD)

◦ Allergic chemicals where immune delayed hypersensitivity reactions occur (allergic contact dermatitis, ACD).

Prognosis Of Occupational Prognosis Of Occupational Dermatitis After TreatmentDermatitis After Treatment

25% complete recovery25% refractory50% remitting / relapsing

How exposure can occurHow exposure can occur

Direct handling

Immersion

Contaminated surfaces

Splashing

Deposition

Classification of ICDClassification of ICD

Acute

Chronic

Clinical Features Of Contact Clinical Features Of Contact DermatitisDermatitis

Location◦Skin disease starts on the area of contact.

Dorsal aspects of hands and finger Volar aspects of arms Interdigital webs Medial aspect of thighs Dorsal aspects of feet

◦ May in face (forehead, eyelids, ears, neck) and arms due to airborne irritant dusts and volatile irritant chemicals

Acute Irritant Contact Acute Irritant Contact DermatitisDermatitis

Commonly seen in occupational accidents Irritant reaction reaches its peak quickly, within

minutes to hours after exposure Symptoms include stinging, burning, and soreness Physical signs include erythema, edema, bullae, and

possibly necrosis Lesions restricted to the area where the irritant or

toxicant damaged the tissue Sharply demarcated borders and asymmetry pointing

to an exogenous cause Most frequent irritants are acids and alkaline solutions

Chronic (cumulative) ICDChronic (cumulative) ICD

Repetitive exposure to weaker irritants -Wet : detergents, organic solvents,

soaps, weak acids, and alkalis -Dry : low humidity air, heat ,dusts ,

and powders

Disease of the stratum corneum

OccupationalOccupational at high riskat high risk

CleanerHousekeepingConstructionFood serviceMedical dentalEngineer

HairdresserMechanicPrinterButcherAgricultural/

GardeningMachinist

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Clinical Features Of Contact Clinical Features Of Contact DermatitisDermatitis

Sign and symptoms

◦Cumulative (exposure to weak irritants) Delayed pain and burning Vesicles and little pruritus Lichenifications, fissures

Case 2Case 2

A builder man presented with erythema , scaling and pruritus on his hands What is your diagnosis ?

Allergic Contact DermatitisAllergic Contact Dermatitis

Caused by low-molecular weight haptens

Hapten is “incomplete allergen”Binds to carrier protein for

immunogenicityLow molecule weight enables

penetration of hapten

Hapten penetrates through stratum corneum of a sensitized individual

A classical Type IV reaction

Allergic contact dermatitis Allergic contact dermatitis

The most common causes of an occupational allergic contact dermatitis are:

1- rubber (23.4% of cases ) 2- nickel (18.2% 0f cases )3- epoxy and other resins (15.6%) 4- aromatic amines (8.6%)5- chromate (8.1%)6- fragrances7- cosmetics (8.0%)8- preservatives (7.3%)

Patch testing with the suspect material will confirm the correct diagnosis

Typically there is an eczematous patch test reaction

Clinical Features ( Acute Clinical Features ( Acute Form )Form )Rash appears in areas exposed to the

sensitizing agent, usually asymmetric or unilat.

Sensitizing agent on the hands or clothes is often transferred to other body parts.

The rash is characterized by erythema, vesicles and sever edema.

Pruritus is the overriding symp.

Clinical Features ( Chronic Clinical Features ( Chronic Form )Form )

Thickened , fissured, lichenified skin with scaling

The most common sites:◦Dorsal aspect of hands◦Eyelids◦periorbital

Chronic OACD in an employee with Chronic OACD in an employee with exposure to exposure to cable filler gelcable filler gel confirmed confirmed with patch testwith patch test

Diagnosis Diagnosis Complete history

◦Occupational◦Non-occupational

Physical examinationPatch test

Patch testPatch test Patch test

Airborne contact Airborne contact dermatitisdermatitis

Airborne Irritant Contact Airborne Irritant Contact DermatitisDermatitis

Develops on irritant-exposed skin of the face and periorbital regions

Often simulates photoallergic reactions

Involvement of the upper eyelids, philtrum, and submental regions help to differentiate from photoallergic reaction

A worker with itchy papules on his forearm What is your diagnosis?

Case 3

DX : DX : Fiber glass dermatitis Fiber glass dermatitis ( kind of CD)( kind of CD)

Mechanism of skin injury is via direct penetration Pruritus and tingling are the usual initial

symptoms

Subsequently erythematous papules develop (often with follicular accentuation) on exposed areas when there is airborne exposure or on the forearms when there is contamination of a work surface

Paronychia is common and airborne exposure

may also cause burning eyes, sore throat and cough

Diagnosis : Clinical findings Confirmed by finding the fibers on

tape stripping of affected skin or examining skin scrapings in KOH 20%.

Course: Resolves rapidly after cessation of

exposure. In most individuals, hardening

occurs and symptoms resolve over a few weeks despite of continued exposure.

Erythematous bullous reaction on the elbow of a gardener and hyperpigmentation after resolving this eruption

What is your diagnosis?

Case 4

Contact Contact photodermatitisphotodermatitisSome chemicals may cause CD only in

the presence of lightSunlight or artificial light sources that

emit specific wavelengths2 categories: -phototoxic -photoallergic

Phototoxic Phototoxic photoallergicphotoallergic

Coal-tar derivativeDyes (Eosin)Drug -phenothiazines -sulfonamidesPlants&derivative -lemon

Antifungal agentsFragrancesHalogenated

salicylanilidePhenothiazinesSunscreensWhiteners

Where involved ?Where involved ?Exposed areas: face, ant. V of the

neck, back of the hand, uncovered sites on the arm&leg

Hairy areas, upper eyelids, and below the chin may be spared

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Case 5

Erythematous patches with tingling on the fingers of a health worker

What is your diagnosis ?

Occupational CausesOccupational CausesLatex allergy ( m/c )FormaldehydeFood industry

◦Plants◦Vegetables◦Animal products

Pharmaceutical industry◦Streptomycin

DX :DX : Contact urticaria (due to Contact urticaria (due to latex)latex)

Pruritus and wheal-and-flare reaction

Develops within a few to 60 minutes of exposure and resolves within 24 hours

It is the protein content of latex rubber that is responsible for the associated contact urticaria

In suspected cases of latex-induced contact urticaria, the specific IgE test may be negative, requiring prick testing with a commercial latex extract

Symptoms include the development of pruritus and localized urticaria soon after donning latex gloves

ManagementManagement of contact of contact urticariaurticaria

1- Avoidance : occupational hygiene use of personal protective equipment ( In

the case of latex, the use of powder-free gloves containing low levels of protein should reduce the development of latex hypersensitivity in the future by reducing the level of exposure

change of occupation2- Systemic antihistamines & epinephrine

depending on the severity of the attack.3- latex desensitization without significant risk

of systemic adverse reactions in the future

Occupational Skin CancersOccupational Skin CancersThe second m/c form of

occupational skin diseasesAbout 17% of all cases of

occupational skin diseases

Occupational Skin CancerOccupational Skin CancerUltraviolet lightPoly cyclic aromatic

hydrocarbonesArsenicIonizing radiationTrauma

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NeoplasmNeoplasmPoly Aromatic HydrocarbonsPoly Aromatic HydrocarbonsDimethylbenzantheracene ,

BenzyprineAfter latent intervals of 6-20

years : keratotic papillomas (tar warts) in

face ,forearms ,hands ,ankles ,dorsal feet ,scrotum

Co factors: UV ,trauma

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Neoplasm Neoplasm ArsenicArsenicChronic exposure: (water, fowlers

solution ,inorganic arsenic)

punctuate ,keratotic papules (arsenic keratosis) ,on palms and soles

No exposed skin surfaces ,intra epidermal SCC (Bowens disease)

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A worker man presented with numerous comedons on his face.

What is your diagnosis ?

Case 7

A worker man with numerous retroauricular comedones and cysts

What is your diagnosis?

Case 8

Environmental AcneaEnvironmental AcneaPreexisting acne vulgaris may be

aggravated by various occupational stress

1-Tropical acne: acne prone individuals employed in tropical climates

2-Acne mechanica: tight fitting work clothing ,pressure from seat belt

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Oil AcneOil AcneLubricating petroleum

greases ,oils ,and pitch fumes may cause follicular plugging and postular folliculitis and is seen not infrequently in machinists and automotive mechanics.

Mechanism : stimulation of follicular keratinization followed by ductal occlusion

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ChloracneChloracne Caused by polychlorinated or poly

brominated aromatic hydrocarbons (halogen acne)

Mechanism: induction of metaplasia ,keratin filled cysts

Noninflammatory comedones and cysts in malar crescents and posterior auricular folds

Poly Chlorinated Biphenyl (PCB)

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Age Age Differential Features of AcneDifferential Features of Acne

Oil acne Any age Acne vulgaris Peak

incidence, ages 11-20

Chloracne Any age

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Distribution Distribution Differential Features of AcneDifferential Features of AcneOil acne Exposed area

Acne vulgaris Face ,Neck ,Chest

Chloracne Face, Especially Malar Crescent

& Auricular Creases, Axillae, Groin, Nose

Spared

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Associated ConditionsAssociated ConditionsDifferential Features of AcneDifferential Features of AcneOil acne None

AcneVulgaris None

Chloracne Xerosis, Conjunctivitis,

Actinic Elastosis, Pheripheral Neuritis,

Liver Abnormalities

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Pigmentary disordersPigmentary disorders

Melanosis -repeated trauma, friction, chemical &

thermal burns, UV -coal tar, pitch, asphalt, creosoteLeukoderma -hydroquinone, phenol -hand & forearms spread

Physical cause of occupational skin Physical cause of occupational skin disordersdisordersMechanical trauma:callus,corn,

lichenficationPermanent callus leading to early

retirementCallus with painful fissure

become infectedPrevention : not necessarilly

heatheatBurn,miliaria, intertrigoBurn: after burn hypopigmentation

susceptible actinic damageHyperpigmentation and scar are

disfiguringMiliria: sweat retention3type: m.crystalina:upper epiderm

m.rubra: lower epiderm m.perfounda: upper dermis

DX : clinical picture, Hx of excessive heat exposure

Prevention: avoiding of exposure, hexachlorophen soap, frequent clothing changes

continuecontinueIntertrigo:macerated,

erythematus lesion in body foldResult excessive sweating in

obese workerCommon site is interdigital space

between third and fourth fingerBacterial and fungal infection is

common

coldcoldFrosbite,chilblainFrosbite: progressive vasoconstriction

cause impairment circulationClinical symptom in mild form:

redness, transient anesthesia, superficial bullae →Initial redness replace by white waxy appearance → blistering & later necrosis

Long-term effects: raynaud-like change paresthesia,hyperhydrosis

Scc develop in old scarRewarming, analgesic, surgical

debridementPrevention: protective clothing,

educating.

coldcold

Chilblain:mild form of cold injuryReddish,blue,swollen,boggy

discoloration with bulla and ulceration

Finger,toe,heel,nose,ear are effectedGenetic is important back groundTreatment : symptomatically

Vibration syndromeVibration syndromeVibration tool in cold weather

produce vasocostriction of digital arteries.(30-300)

pallor, cyanosis, erythem of finger named raynaud phenomen

Papular name : dead or white finger.

Tingling,numbness,blanching of the tip of finger occurred

Asymmetry is diagnosticPrevention: designe of tools,

insulation, protection of hands from cold weahter.

With thanks